While the typical youthful Asian upper eyelid is fuller than in the Occidental, lid hollowing is a common change in the Asian population that can begin during the early twenties. As the fat inside the socket begins to decrease, it becomes less effective at inflating the upper eyelid from behind. A depression appears midway between the brow and lashes due to this deep underlying fat loss.

Although the same sort of aging change may occur in anyone, it is much more common in people of East Asian and especially South Asian or Indian descent.

As time progresses, the depression may deepen considerably and cause the overlying skin to sink into a fold vaguely mimicking an upper crease but more commonly a series of tiny incomplete folds, a feature sometimes called a "triple eyelid." The contour of the bone above the eye may become plainly visible above the hollow.

Because a hollowed eye is a feature seen most commonly in the older Asian person, its occurrence during younger years can be worrisome because it makes the face look older. A similar and often more severe form of hollowing may occur after inappropriate fat removal during double eyelid surgery.

Treatment presents a challenge. Minimal changes are best left alone. If hollowing becomes advanced, the only workable option involves placing a fat graft to plump up the skin from behind.

Early efforts now abandoned were directed at implantation of tiny silicone-filled bags not unlike miniaturized breast implants the size of a medicine capsule. Alternatively, strips of fascia removed from the muscle of the temple were sometimes threaded into the eyelid.

Currently, the most effective approach for permanently enhancing deep volume entails open grafting of pearl-size pieces of fat from the lower abdomen directly into the orbit (eye socket). Injection of liquified fat obtained by liposuction is a much simpler procedure but is seldom recommended because of rapid resorption and the increased risk from sticking needles into the area around the eyeball without visualization.

Injection of hyaluronic acid designed as a dermal filler has been reported to yield satisfactory but temporary improvement in cases of milder eyelid hollowness lasting up to 18 months.

Unable to permanently correct the underlying cause, some plastic surgeons may recommend removing deflated and folded skin below the depression to try to create a single "crease." In the absence of adequate volume, however, a true crease cannot form, and many patients consider the resulting high arch to look worse than the starting point.

Treatment of this vexing but not uncommon Asian cosmetic condition remains problematic as no procedure can predictably yield the precise amount of correction and symmetry typically demanded by many younger patients.